Corrosive poisoning by Dr.Ashwin Menon

CORROSIVE POISONING

DR.ASHWIN MENON

• An average home contains a dozen different cleaning products. These are responsible for a large number of accidental and intentional poisoning.

• Incidence :- 2.5 - 5%• Mortality :- 13%• Morbidity :- > 50%• About 80% of corrosive poisoning occurs in children < 5

yrs.

INTRODUCTION

INTRODUCTION

• The route of entry of corrosive substances in the body is:

– ingestion– inhalation (rarely)

• Adult exposure has more mortality & morbidity due to significant volume of exposure & possible co-ingestion.

CLASSIFICATION

THREE TYPES

ACIDSALKALIS

(Most dangerous)

OXIDANTS

FACTORS DETERMINING CORROSIVENESS

Factors that determine corrosiveness include:

• Physical form: Solid/liquid

• Duration of contact with tissue

• Concentration of agent

• Quantity of agent > 100 -150ml - Massive poisoning

FACTORS DETERMINING CORROSIVENESS

• pH of agent: pH <2 and >11 are morevcorrosive

• Food: Presence or absence of food in stomach

• Titratable acid or alkali reserve (TAR): This quantifies the amount of neutralizing substance required to bring the pH of a caustic agent to physiological pH of the tissue.

EXAMPLES

ACIDS

• SULPHURIC ACID - CAR BATTERIES• NITRIC ACID – METAL CLEANERS• HYDROCHLORIC ACID & ACETIC ACID -DESCALERS• PHENOL & BORIC ACID -DISINFECTANT• HYDROFLUORIC & OXALIC ACID – RUST REMOVERS

ALKALIS

• AMMONIA – HOUSE HOLD CLEANERS & LAUNDARY DETERGENTS• BLEACH – DISINFECTANT• SODIUM HYDROXIDE - DRAIN CLEANERS

MECHANISM OF INJURY

ACIDS

ACIDS

• They ppt protein → Coag.→ Necrosis • Coagulum forms a barrier and limits further damage.• Sq. epithelium of pharynx and oesophagus are resistant

to acids.• Stomach (Antrum) is the most commonly involved

organ.• Most common complication is perforation occurring on

3 or 4th day.• In the presence of food gastric injuries tend to be less

severe and involve the lesser curve and pylorus.

ALKALIS

ALKALIS

• They saponify fats & dissolve proteins → liquifactive necrosis & rapid injury.

• Sq. epithelium of pharynx and oesophagus (lower half) are the most commonly affected parts.

• Most common complication is stricture - 2 to 4 weeks.– Development of stricture depends on the depth of the burns.

o Superficial (Superficial to muscularis mucosa) 1%o Deep - 70-100%

• Disk shaped batteries are easily swallowed but if they get lodged in the oesophagus, they cause injury by – – Leakage of alkali : direct caustic injury– Absorption of toxic substances– Pressure necrosis– Electrical discharge → Mucosal burns

ALKALIS

Chest radiograph of a child who has ingested a coin-shaped battery

SEQUELAE

• Lead to:– Oesophageal burn without perforation– Oesophageal burn with perforation– Tracheo oesophageal fistula– Aorto oesophageal fistula

HISTOPATHOLOGIC EVENTS ASSOCIATED WITH 10% SODIUM HYDROXIDE BURN OF

OESOPHAGEAL MUCOSA

• Oedema of submucosa• Inflammation of submucosa with thrombosis• Sloughing of the superficial layers• Necrosis of the muscular layer• Fibrosis of the deep layers• Delayed re-epithelialization

LUNG TISSUE

RENAL TUBULAR NECROSIS

CLINICAL FEATURES

GIT

• Severe pain of lips, mouth, throat, chest and abdomen• Excessive salivation• Dysphagia and odynophagia• Epigastric pain and hematemesis• Symptoms and signs of GI perforation

Respiratory system• Cough• Dyspnea• Bronchoconstriction• Pulmonary oedema• Chemical pneumonitis

Eyes and skin• Pain at the site of exposure• Burns at the site of exposure• Erythema and vesicle formation

MANAGEMENT

1. Accurate history defining what and amount of ingestion occurred.

2. ABCs– Treat like a burn

3. Evaluate for hoarseness, stridor, drooling, odynophagia, refusal of food.

4. Palpate for subcutaneous air

5. Rigidity and sub sternal chest pain

6. Assess for emesis. -Increased laryngeal/oesophageal exposure

MANAGEMENT

INVESTIGATIONS

1. Test the pH of the saliva. Neutral pH does NOT mean caustic ingestion did not occur.

2. Labs -CBC -ABG -Urine

3. CXR -Pneumomediastinum -Button battery4. KUB -Pneumoperitoneum -Button battery5. CT -Use water soluble contrast.6. Technetium 99m–labeled sucralfate study

INVESTIGATIONS

X ray neck- oesophageal perforation

Esophageal rupture with right pneumothorax with midline shift

Barium oesophagogram of a perforated esophagus. Arrow shows the extravasation of contrast into the left chest

CT scan of a perforated esophagus. Note the air andfluid in the mediastinum.

Lesion in the gastric antrum (arrows) demonstrated by x-ray

Scintigraphy - Note retention inarea of the lesion on both 1-hr and 2-hr images.

Uptake in fundus of stomach is also persistent although no pathologyexisted in this area.

ENDOSCOPY

When to perform?-Optimally performed 6 - 24 hrs.

Why?-Because if performed earlier the full extent ofthe injury may not be apparent.-If performed later the risk of the perforation is high (especially with rigid endoscopy)

• First assess the cricopharynx and then larynx If burns are noted prophylactic ET.

ENDOSCOPY

• Where Oesophagoscopy should not be performed?

– haemodynamically unstable patients.– evidence of GI perforation.– Patients with significant airway oedema.

• If the patient presents >48 hours after initial ingestion, barium swallow may be considered instead of Oesophagoscopy.

• Anatomical areas of narrowing oftentimes receive the most damage-

-Cricopharyngeal area (UE)-Aortic arch-LES-Antrum/body of stomach

• These are also the most common sites of stricture formation.

Endoscopic view of the epiglottis and vocal cords 4 days after ingestion.

Endoscopic view of the epiglottis and vocal cords 11 days after ingestion.

ENDOSCOPIC GRADING-KIKENDALL CLASSIFICATION

I GRADE: Oedema and erythema of the mucosa

II A GRADE: Haemorrhage, erosions, blisters, superficial ulcers

II B GRADE: Circumferential lesions

III GRADE: Deep grey or brownish-black ulcers

IV GRADE: Perforation.

ENDOSCOPIC GRADING -ZARGAR’S CLASSIFICATION

GRADE 1 Erythema

GRADE 2(a) Superficial localized ulcer, Friable Erosion,Haemorrhage, Exudate.

GRADE 2(b)* 2(a) + Localized deep, discrete orcircumferential ulcers

GRADE 3(a)* Small Scattered areas of necrosis

GRADE 3(b)* Extensive circumferential necrosis

* Lead to Strictures

OesophagoscopyA. Grade 2A. B Grade 2B of stomach B. C 3A of stomach D. 3B of stomach

FOUR STAGES OF OESOPHAGEAL BURNS

VIDEO 1

CINE - OESOPHAGOGRAPHY• Detects motility disorders

• Atonic rigid oesophagus• Atonic dilated oesophagus • Abnormal un co-ordinated contractions

*Cine Oesophagram is a video version of Barium Swallow.

LaterDevelop intoStrictures

TREATMENT

TO DO:

IMM. DILUTION WITH PLAIN WATER 5ml/kg.

SECURE AIRWAY I.V.FLUID PROPHYLACTIC AB’S H2 BLOCKERS SUCRALFATE 1gm/6hrs. MONITOR ACID BASE & ELECTROLYTES

STATUS.

NOT TO DO:

GASTRIC LAVAGE EMESIS NEUTRILIZATION ACTIVATED

CHARCOAL CARBONATED DRINKS

WHY – NOT TO DO?

GASTRIC LAVAGE : Risk of perforation(Immediate lavage within 1-2 hrs. after large

volume of ingestion is beneficial)

EMESIS : Leads to new exposure and risk of aspiration.NEUTRILIZATION : Leads to heat production more

injury.

ACTIVATED CHARCOAL : Obscures endoscopic view.

STEROIDS?

Role of steroids controversial.• Animal studies have proven to be beneficial, but human evidence lacking.

Local injection of TRIAMCINOLONE is also beneficial.• Steroids definitely have a role in preventing laryngeal oedema.

- Prednisolone 1 - 2mg/kg/6 hrly. for 2 weeks.- Contraindicated if perforation.

PHARMACOLOGIC THERAPY

CALMS

Corticosteroid

Antibiotics

Lathyrogenic agents-β-aminopropionitrile, N-acetylcysteine, and penicillamineMitomycin

Sucralfate

MECHANICAL THERAPY

• The simplest mechanical method for maintaining a lumen in a third degree oesophageal burn is to place a nasogastric tube at the time of initial endoscopy.

• Other types of stents used are polymeric silicone tubes in the oesophagus.

• The important type of stents that are available on the market are1. Polyflex2. Ultraflex3. Z stent4. Bonastent

SELF EXPANDING STENT

VIDEO 2

• Mild strictures can be serially dilated in a prograde fashion through an oesophagoscope with filiform dilators.

• Fluoroscopic guided balloon catheter dilation for acquired strictures has shown little success.

VIDEO 3

ENDOSCOPIC LUMEN RESTORATION (ELR)

• Multiple strictures are managed most safely with retrograde dilators, popularized by Tucker.

• ELR is best accomplished by a multidisciplinary approach including an experienced gastroenterologist/endoscopist, an otolaryngologist, and a swallowing therapist (speech pathologist).

A) Barium swallow shows mid-oesophageal stricture afteralkaly ingestion in an adolescent 4 weeks after ingestion and at thebeginning of retrograde dilations.

B) Same patient 5 years later, after 4 years of repetitive dilations; the patient has a stable stricture and is generally non symptomatic.

A B

• Esophageal replacement with gastric tubes, right colon, transverse colon, or descending colon has been described.

• The right colon has been reported to be the most useful conduit.

• Gastric outlet obstruction as a complication of acid ingestion is well known.

• Presenting symptoms include – frequent non-bilious emesis– secondary marked weight loss.

Treatment is surgical and includes -Gastro-jejunostomy or Billroth I for complete

obstruction -The Finney or Heineke Mikulicz pyloroplasty for partial obstruction.

BILLROTH 1

Heineke-Mikulicz Pyloroplasty

ORAL FEEDING, WHEN TO START?

GRADE-1 INJURIES ON ENDOSCOPY- DAY 1

GRADE-2 INJURIES ON ENDOSCOPY- LIQUID FOODS AFTER 48-72 Hrs.

GRADE-3 INJURIES- NIL ORAL- FEEDING JEJUNOSTOMY /TPM

TREA

MEN

T AL

GORI

THM

CONCLUSION

• With corrosive poisoning the injury ranges from minimal mucosal erythema to frank transmural necrosis of the oesophagus and stomach with viscous perforation.

• Full length oesophageal endoscopy is the most accurate initial method of examination, and is indicated after any ingestion of a strong liquid alkali.

• Oesophageal stricture formation is the chief long-term complication with a potential devastating impact on quality of life. Although repetitive stricture dilations are the mainstay of management, prevention or reduction in the severity of this complication is promising.

CONCLUSION

THANK YOU …